A meta-analysis of transcarotid versus transfemoral transcatheter aortic valve replacement

An Updated Comprehensive Review of Existing Transcatheter Aortic Valve Replacement Access

For the past 20 years, transcatheter aortic valve replacement (TAVR) has been the treatment of choice for symptomatic aortic stenosis. The transfemoral (TF) access is considered the gold standard approach for TAVR. However, TF-TAVR cannot be performed in some patients; thus, alternative accesses are required. Our review paper generalises the TAVR accesses currently available, including the transapical, transaortic, trans-subclavian/axillary, transcarotid, transcaval, and suprasternal approaches. Their advantages and disadvantages have been analysed. Since there is no standard recommendation for an alternative approach, access selection depends on the expertise of the local cardiac team, patient characteristics, and access properties. Each TAVR centre is recommended to master a minimum of one non-TF access alternative. Of note, more evidence is required to delve into the clinical outcomes of each approach, at both early and long-term (Figure 1).

Post-TAVR conduction abnormalities leading to permanent pacemaker implantation: Risk factors, prevention, and management

Transcatheter aortic valve replacement (TAVR) often leads to conduction abnormalities, necessitating pacemaker implantation. This review of 38 meta-analyses identified preexisting right bundle branch block (RBBB), LAHB, and new-onset left bundle branch block as key risk factors, with a higher PPM risk in male and older patients. Procedural factors like transfemoral access and self-expandable valves also increase this risk. Prevention focuses on tailoring TAVR to individual electrophysiological and anatomical profiles. However, there's a lack of consensus in managing these conduction disturbances post-TAVR, highlighting the need for further research and standardized treatment strategies.

Comparison of Alternative Peripheral and Transfemoral Approaches for Transcatheter Aortic Valve Replacement: A Meta-Analysis of Propensity-Matched Studies

Background. Transfemoral (TF) access is the gold standard for transcatheter aortic valve replacement (TAVR). Alternative peripheral (AP) artery access such as the carotid or axillary artery is considered when the feasibility of femoral access is in doubt. The outcomes comparison of these 2 approaches is unclear due to limited sample sizes in prior studies. Our aim is to compare the clinical outcomes of TF- and AP-TAVR by conducting a meta-analysis of propensity-matched studies. Methods. The PubMed, EMBASE, and Cochrane Library databases from inception up to and including February 2022 were searched by 3 separate researchers to identify articles reporting propensity-matched, comparative data on TF vs. AP-TAVR. Clinical outcomes were extracted from the articles and pooled for analysis. Results. Seven prior studies, including 9,004 patients, were included in our study, with 6,729 in the TF group and 2,275 in the AP group. In all studies, the baseline characteristics of the patients were highly propensity-matched with the full Newcastle-Ottawa scale. Meta-analysis revealed higher in-hospital/30-day mortality (3.3% vs. 4.4%; OR 0.69; 95% CI (0.51, 0.94); $P=0.02$ ) as well as the incidence of stroke (1.9% vs. 3.5%; OR 0.60; 95% CI (0.43, 0.84); $P=0.003$ ) for the AP group. There were no significant differences in the incidence of major vascular complications, pacemaker implantation, bleeding, or acute kidney injury. Conclusions. Our meta-analysis of propensity-matched studies showed AP-TAVR contains an additional 1.1% risk of early mortality and an additional 1.6% risk of stroke compared to TF-TAVR. These risks should be considered when deciding on access.